CLC documentation _rev 21032024.pdf

Official (Open) CONSCIOUS LEVEL ASSESSMENT AND DOCUMENTATION LEARNING OUTCOMES At the completion of this lesson, the students will be able to: 1. State the assessment components items in a Conscious Level Chart (CLC)....

Official (Open) CONSCIOUS LEVEL ASSESSMENT AND DOCUMENTATION LEARNING OUTCOMES At the completion of this lesson, the students will be able to: 1. State the assessment components items in a Conscious Level Chart (CLC). 2. Perform a neurological assessment using the CLC which will include: Glasgow coma scale. assessment of the temperature, pulse, respiration and blood pressure. assessment of the pupil size and reaction. assessment of the motor strength. 3. Identify normal and abnormal responses in this neurological assessment. REFERENCES Christensen, B. (2018). Medscape: Glasgow Coma Scale-Adult. Retrieved from https://emedicine.medscape.com/article/2172603-overview Glasgow Coma Scale (n.d.). The Glasgow Structured Approach To Assessment of The Glasgow Coma Scale. Retrieved from: https://www.glasgowcomascale.org/ Lippincott Procedures. (2018). Neurologic Assessment. Retrieved from https://procedures.lww.com/ Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2018). Clinical nursing skills and techniques. (9th. ed.). St. Louis: Mosby Elsevier. Shobhit, J., Lindsay., Iverson, M., (2022) Glasgow Coma Scale – StatPearls – NCBI Bookshelf LEARNING ACTIVITIES Demonstration and practice. Attempt e-quiz exercises in Brightspace (BS). INSTRUCTION FOR STUDENTS Student to bring a pen torch. Female students (“model”) to wear pants..1 Official (Open) CONSCIOUS LEVEL CHART (CLC) PURPOSE To perform neurological assessment and assess for changes in the neurological status of patient. GLASGOW COMA SCALE (GCS) 1) Best eye opening response 2) Best verbal response 3) Best motor response Highest score - 15 (fully alert, well-orientated person). Lowest score - 3 (deep coma). SCALING OF EYE OPENING Assess eye opening responses using appropriate stimulus eg. voice, shake or pain. Score Responds Explanation The patient opens eyes spontaneously without external 4 spontaneously stimulus indicates that the arousal mechanisms in the brainstem are active but does not imply awareness. The patient opens eyes to sound of voice either spoken or 3 to speech shouted. The patient opens eyes to painful stimuli such as pain on the 2 to pain fingertip. 1 none The patient does not open eyes to any stimuli. Note: Record "C" if eyes are closed due to periorbital oedema or with injury. If patient is sleeping, arouse patient with appropriate stimulus prior to conducting the assessment. SCALING OF VERBAL RESPONSE Assess verbal response through questioning. Score Response Explanation The patient is oriented to time, place and person i.e. 5 orientated awareness of self and the environment. 4 confused The patient is able to converse but gives irrational replies. The patient speaks random words or phrases that make inappropriate 3 little or no sense i.e. articulation but no conversational words exchange. incomprehensable The patient responds with groans and moans without any 2 sounds sounds/recognisable words. 1 none The patient do not respond verbally. Note: Record "T" if patient is on endotracheal tube or with tracheostomy..2 Official (Open) SCALING OF BEST MOTOR RESPONSE Assess patient's best arm motor response eg. if patient follows command with right arm and localise pain on the left side, document best motor response as obeys commands. Score Response Explanation The patient follows simple commands eg. grip and release 6 obey commands hand; lift up limbs. The patient is able to locate painful stimuli applied by the 5 localise pain assessor and attempts to remove the source. 4 flexion to pain The patient flexes limbs to painful stimulus. The patient's arms are adducted and flexed and his wrists abnormal and fingers are flexed on the chest. 3 flexion The legs may be stiffly extended and internally rotated, with plantar flexion of the feet. (decortication). The patient's arms are adducted and extended with the extension to wrists pronated and the fingers flexed. 2 pain One or both legs may be stiffly extended, with plantar flexion of the feet. (decerebration). 1 none The patient has no motor response to pain on any limb. Assess patient’s best motor response ▪ If the patient does not obey commands, then next step is to apply the painful stimulus: o Peripheral Stimulus o Central Stimulus Peripheral Stimulus (Peripheral Pain) Peripheral stimulus is to apply pressure to the distal part of the patient’s fingernail for 10 seconds to elicit a response. Varying the finger should be used to minimise potential harm. Localising pain: Peripheral pain is applied to the distal part of the patient’s fingernail, the patient responded by purposeful movement towards the pain to remove the source of painful stimulus. Central Stimulus (Central Pain) Central stimulation is first applied by applying pressure to the trapezius muscle (testing Cranial Nerve XI) for 10 seconds to elicit a response particularly for localising movement: Localising pain: Central pain is applied to the trapezius muscle, the patient purposefully moves the arm to remove the source of pain i.e. across the midline of the body or above the clavicle.3 Official (Open) Although it is easier to elicit localizing pain using the trapezius squeeze, however, it may give rise to bruises at the site of the trapezius muscle because CLC is frequently monitored hourly. ▪ Apply painful stimulus by squeezing patient’s trapezius muscles (testing Cranial Nerve XI) for 10 sec to elicit a response. ▪ Findings: - ▪ If the patient purposefully moves his arm to remove the source of pain i.e. across the midline of the body or above the clavicle, is localise to pain (5). ▪ If the patient responds by trying to flex his arms towards pain source, but he cannot removes the pain source , is known as normal flexion (4). ▪ All painful stimulus should be given with a gradual intensive to elicit a respond not more than 10 sec. **Avoid using supraobital notch, only to be done by trained professional. P.S. Any variations in practice, please follow the hospital guidelines and practice. DECORTICATE (ABNORMAL FLEXION) The decorticate posture may indicate a lesion of the frontal lobe, internal capsule, or cerebral peduncles. DECEREBRATE (EXTENSION TO PAIN) The decerebrate posture may indicate lesions of the upper brain stem..4 Official (Open) GCS SCORE 13-15 = Mild head injury 9-12 = Moderate head injury 8 or less = Severe head injury VITAL SIGNS Monitor BP, PR, RR and temperature as ordered by doctor. Signs of  intracranial pressure: -  BP -  pulse rate -  respiratory rate - widen pulse pressure PUPILLARY SIZE AND RESPONSE Note the size, shape and symmetry of both pupils. - Shine a bright light source from outer canthus to the inner canthus into each pupil and note the reaction. - Both pupils should constrict briskly and equal in size unless underlying condition is present, then the reaction may be sluggish or fixed and the size will vary. Normal pupils size at 3-5mm. Normal pupils should be PERRLA = pupils equal, round, reactive to light and accommodation. TTSH chart SGH chart Actual record of pupil reaction: Record: B for brisk + for reactive S for sluggish - for non reactive F for fixed C eye closed by swelling.5 Official (Open) LIMB MOVEMENT AND MOTOR STRENGTH Compare the power of the right and left limbs, include the assessment of all four limbs. Score Discription Explanation Extremity movement can overcome gravity and 5 normal maximum resistance. Extremities are weak, but patient can move arm or leg 4 mild weakness against gravity and overcome mild to moderate resistance. Extremities can be lifted off the bed but cannot 3 > anti-gravity strength overcome resistance when applied. Extremities can move along a non-gravity plane only 2 < anti-gravity strength (not able to lift off the bed). minimal strength (TTSH) 1 Minimal movement on the bed. severe weakness (SGH) no movement (TTSH) 0 Absent movement. no response (SGH) Note: For lower limb, there is no abnormal flexion assessment. DOCUMENTATION Place a cross (X) or ( ) round dot for vital signs in the appropriate box of the Glasgow Coma Scales according to hospital protocol. For BP charting, indicate using up and down arrow key or dot accordingly. Any abnormalities in the neurological assessment should be reported to the doctor immediately to prevent irreversible damage to the brain. Document along the vertical column the name of the doctor informed of the deterioration of patient's neurological status. Also record the time in the corresponding column..6 Official (Open) PERFORMANCE CHECKLIST – CONSCIOUS LEVEL ASSESSMENT Assessment Assess the patient’s − Need for monitoring of neurological status. − Frequency of monitoring. Planning Equipment: gathers appropriate equipment. Environment: ensures a safe environment and privacy. Patient: Check patient's identity. Explain procedure to patient to allay fear and anxiety and gain. cooperation (where applicable). Implementation Accuracy − Use correct method to assess the following components in the CLC: ▪ Eye opening. ▪ Best verbal response and motor response. ▪ Pupil size and reaction. ▪ Limb movement and motor strength. Vital signs − record observations correctly. Safety − apply pressure gently during assessment. Evaluation Record observations correctly. Report relevant observations..7 Official (Open).8